Provider Demographics
NPI:1356860340
Name:ROBERTS, BAILEY NICOLE (AT, ATC)
Entity Type:Individual
Prefix:MISS
First Name:BAILEY
Middle Name:NICOLE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43045-8008
Mailing Address - Country:US
Mailing Address - Phone:810-522-7136
Mailing Address - Fax:
Practice Address - Street 1:93 W CENTER ST
Practice Address - Street 2:
Practice Address - City:MILFORD CENTER
Practice Address - State:OH
Practice Address - Zip Code:43045-8008
Practice Address - Country:US
Practice Address - Phone:810-522-7136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OHAT0058562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program